30 HIGHLAND AVE - BUILDING INSPECTION '14
AfkPROVED BY T44E
AIaPFX .. J.- RIOR TP!A�PERiVllT .B,EWG GRANTED
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CITY OF SALEM
No. Zf 3-z-6 0 t-I Date z)0�✓
Ward
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Zoning District
Is Property Located In Location of
the Historic District? Yes_Noz Building 135- 494W10 Al
IsProperty Located in
the Conservation Area? Yes—No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply)6Roo 6roof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name -A"16� ChAd
Address & Phone -� 41L44LA140 Nit- (5ig) WIMIS3
Architect's Name
Address & Phone
Mechanics Name" �AWJM 01-t K 6AAPACre45
Address & Phone dl d' d4r11,f AX Sr (92g) 531-166
What Is the purpose of building? p4sliltorlht-
Material of building? WC0 0 If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost City License # /5'042 state.ocense #
Home Improveme t AA Kat
1 1602 3"'
5 C�-- C,r 52
Lie. Sig fIature of T prcant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
To sji(p tx6111V6 1,- Abrg;04 A1411- Sdx4Ww,-1P5f,411
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44 t1t-Kq1 L4 rov
MAIL PERMIT TO: A0
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rn - OF SALEM,, MAS5Ach1u%c i
PUBLIC AFZ�0PERTY DEPARTMENT
• '• 120 WASHINGTON STREET, 3RD FLOOR -
< SALEM,MA 01970
' TEL, (978)745-9595 EXT.380
FAX (978) 740-9B46
iTANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,SA I aclmowledge that as a condition
of Building Permit# all debris resulting from the cons r"ction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A.
nn �
The debris will be disposed of at • F a W �
Location of Facility
Iy U
gnature of P Applicant D e
FULLY complete the following information.
(PLEASE PRINT CLEARLY)
Cr9w
Name of Permit Applicant
Firm Name,if any
Address, City & State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL clll,S 150A, and the building permits Or licenses are to
indicate the location of the facility.
fommonvioahk 01 Ma3�6ack"69ffs
'— J/ epa�In=snf dJ.,7adtsfriaf lrcciafenls
5 = t�',
n/ 600 eeyWaskjim
famesJ.Camooes Uo ton, /!lasaechua.w 02111
Conimssasrla
Workers' Compensation Insurance Affidavit
tt�UJ�2 ci;1 CGuI'Mcfe
wish.a principal place of business at:
tcanisea=✓slrl
do hereby'cerdly under the pains and penalties of pujmy, that
1 am an employer providing workers' compensation coverage for my employees working on
/ this job.
Insurance Company Policy Humber
1 am a sole proprietor and have no one working for me in any caWcity.
O 1 am a sole proprietor, general contactor or homeowner (circle one) and have hired the
on olities:
contractors listed below
who have the following workers campensatt p
Contractor Insurance Company/Polity Number
Contractor Insurance Company/Polity Number
Contractor insurance Company/Polity Number
0 1 am a homeowner performing all the work myself.
I unoen and wt a copy of thu weN t wE be f,aretc w the Once of In,dt+ocnt of the DIA low coecrate eerfficadon and Unit blare to"Cure
cc. atr of reoureo uncer Secion 2SA of MCL 15 2 can lead to the:noowon of crarirui ocnmaes corutdnt of a fee of so=41.50000 a Wer one
reary' iraruonnrcnt a+.crs as[ri xnaldtl rat th< I= of, STOP WORK ORDER and 7 fne of S 100.00 a day atirot m-
Signe this , JAJD day of
cc sce/Pcrniu building Departrwent
Ucensing Board
Seiectmens Office
He2ith Dcparsment
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